WRNMMCB Bariatric Information Check List

Transcription

1 Bariatric Information Check List Please refer to our bariatric surgery website for additional information. If you are unable to find an answer to your concern, please refer to the contact numbers below. Website: General Surgery-Bariatric Program: (301) Patient s Name Type of surgery to be performed: PCM: I have ordered the following lab work & radiologic studies: [complete below or make notations in AHLTA note. See AHLTA order set under Bariatric Eval HL v ] I will ensure that my health maintenance issues are addressed by my PCM, e.g. mammograms and colonoscopies as indicated Complete Metabolic Panel The following results were abnormal: Complete Blood Count The following results were abnormal: Vitamin D (calcidiol/25-hydroxy Vit D) The following results were abnormal: TREATMENT PLAN for abnormal lab results: Ultrasound Right Upper Quadrant IF gallbladder still present EKG (for male age > 40, female age > 50, sedentary lifestyle) was done on o Results: Cardiac Risk Stratification (IAW ACC/ AHA guidelines): _e.g. ECHO? 1-5

2 Regarding EXERCISE, this patient: How long have the patient been morbidly obese has no restrictions for physical activity and has started a walking or other exercise program as required prior to bariatric surgery. has the following restrictions for physical activity: These conditions are being optimally managed with the following: I recommend this patient for bariatric surgery and confirm that all health problems are being optimally medically managed in preparation for major surgery. Full H&P of systems with final letter of recommendation clearing patient for surgery. PCM s Signature: Date: Dietitian (see dietician phone list on website). If done WRNMMC call the Bariatric line at Must cont. every 4wk till your surgery and after. This patient has completed the required 3 pre-op MNT appointments on the following dates w/ compliance: Visit #1 lbs lost food/exercise log kept? Yes/No Visit #2 lbs lost food/exercise log kept? Yes/No Visit #3 lbs lost food/exercise log kept? Yes/No Over 3 visits total lbs lost was,. Patient understands 10 lb pre-op weight loss is required. From a nutrition standpoint this patient is: a good candidate for bariatric surgery due to a BMI of kg/m², multiple previous unsuccessful diet attempts, and a demonstrated understanding of and willingness to follow the diet Rx post-op. 2-5

3 not recommended for bariatric surgery for the following reason(s): Dietitian s Signature: Date: Exercise Therapist: Must also be seen at your 3, and 6 months post Bariatric surgery. This patient has had the required 1 pre-op evaluation on the following date: Exercise Rx: I recommend this patient for bariatric surgery I do not recommend this patient for bariatric surgery for the following reason(s): Exercise Therapist s Signature: Date: Psychology Evaluation: Dr. Grubb / Dr. Evans This patient completed the required pre-op evaluation on the following date: See AHLTA note for one of following conclusions: No contraindications to surgery. There are no absolute contraindications to surgery, but I have the following concerns: Patient should have the following conditions treated before surgery: Patient is not recommended for surgery for the following reason(s): Behavioral Health Provider s Signature: Date: 3-5

4 Support Group (see list on website for locations) This patient participated in a bariatric pre-op support group (x2) on the following dates: #1 Date: Location: Facilitator s Signature: #2 Date: Location: Facilitator s Signature: Sleep Study: Most will be referred out. If done outside a MTF please bring all documents in. CPAP/BiPAP not recommended CPAP/BiPAP recommended Setting: Signature: Date: Endoscopy: Need of an endoscopy will be determined by the surgeon during your PreOp. This patient completed the required pre-op endoscopy on the following date: H Pylori: If positive, was patient treated? If you desire the Sleeve Gastrectomy, we ask you to consider enrollment in our sleeve study to predict difficult to control heartburn postoperatively. a. Call for PH probe & manometry appointment b. Resting LES pressure: Signature: Date: 4-5

5 Patient Prepare Mentally and Emotionally: I understand the surgery I will be having. I have read all information given to me by the clinic staff. I know that I should abstain from drinking alcohol preoperatively, for 2 years post-operatively, and preferably avoid alcohol for the rest of my life I can commit to the changes in my lifestyle, such as the new diet and exercise program, and continuous follow up with my surgeon, dietitian, and exercise physiologist. I discussed having bariatric surgery with my family and /or friends. I know where to get the information and support I need for this journey How long do you remember being obese? What prior attempts at weight loss have you included, e.g. Jenny Craig, Weight Watchers, Adkin s or Phen-Fen. (Please List): Initial Lifestyle Changes: I have started changing my diet to align with recommendations. I have lost at least 10 lbs since I was referred by my PCM. I have kept my food and exercise logs throughout this process. I have stopped smoking since enrolling in the program (if I had ever smoked at all). I have started an exercise program walking as tolerated, swimming, I understand that I must adhere to a 2 week pre-op liquid protein diet. What was your score on the Bariatric Pre-Op Quiz? Patient s Signature: Date: 5-5